Magnolia Manor of Midway

Inspectors wroteBased on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure three of five residents (R) (R2, R6, and R69) reviewed for pneumococcal/flu vaccines was offered a pneumococcal and flu vaccine and were provided the risks and benefits for pneumococcal and flu vaccines. The facility failed to ensure that two of five residents (R3 and R75) were provided with the risks and benefits prior to receiving the pneumococcal vaccine. This had the potential for the residents to have an increased risk of contracting pneumonia and flu, and for those who received the pneumococcal and flu vaccines without consent, and providing the risks and benefits did not provide the residents and or representatives the right to make an informed decision before being given the pneumococcal vaccine.

Inspectors wroteBased on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure one of five residents (R) (R2) responsible party had received the risks and benefits explained before they declined for the resident to receive the COVID-19 vaccine/ booster. The facility failed to ensure that two of five residents (R6 and R75) responsible parties, received the risks and benefits before receiving the COVID-19 vaccine/booster. Additionally, the facility failed to ensure two of five residents (R69 and R3) responsible party were given the opportunity to make a decision if they wanted their residents to receive a COVID-19 vaccine/ booster. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to prevent abuse for three of 26 sampled residents (R) (R1, R23, and R8).

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime and reporting of all alleged abuse violations to the State Agency (SA) for three of 26 sampled residents (R) (R1, R23, and R8).

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to develop a comprehensive care plan following victimization of abuse for two of 26 sampled residents (R) (R1 and R23).

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to revise a comprehensive care plan following aggressions of abuse for one of 26 sampled residents (R) (R8).

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure assistive devices and treatment were attempted for one of seven residents (R) (R69) reviewed for positioning/mobility. This had the potential for the residents to experience a further decline in range of motion (ROM).

Inspectors wroteBased on observation, record review, interviews, and review of policies and procedures, the facility failed to assess the entrapment risk of bedrails used for mobility assistance and obtain consent for one of three residents (R) (R47) reviewed for accident hazards.

Inspectors wroteBased on observation, interviews, record review, and a review of the facility policies titled Admissions and Medication Orders, the facility failed to protect one of 33 sampled residents (R) (R4) with allergies. Harm was identified to have occurred on 9/24/2025 when R4 was administered Bactrim DS (an antibiotic medication) that was listed as a known allergy for the resident, resulting in an allergic reaction to the medication (flushing (feeling hot), redness, and rash).

Inspectors wroteBased on observation, interview, record review, and review of facility policy titled Medication Orders and Admissions revealed the facility failed to order an anticonvulsant for one of 17 sampled residents (R) (R1) who received an anticonvulsant for seizures and an antibiotic. Harm was identified to have occurred on 2/15/2025, when R1 was rehospitalized for seizure activities due to not receiving the required anticonvulsant medication.

Inspectors wroteBased on observations and staff interviews, the facility failed to properly label opened food items in the walk-in refrigerator and walk-in freezer, discard expired foods in the walk-in refrigerator, clean the ice machine, and ensure that kitchen staff wore beard guards while in the food preparation area. These deficient practices had the potential to adversely affect the 72 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policy titled Treatment of Residents, the facility failed to ensure privacy was provide during Activity of Daily Living (ADL) care for one of nine residents (R) (R23), the facility also failed to ensure a privacy bag was provided for one of three residents R7 that utilized a urinary catheter.

Inspectors wroteBased on observations, staff interviews, record review, review of facility documents, and review of the facility policy titled, Residents' Rights Protection, the facility failed to ensure one of nine residents (R) R18 was provided with a chair that accommodated his height and ensured body alignment. The facility also failed to ensure two of 28 residents, R16 and R51 were assessed for placement on the Secured Unit (Unit 3). The deficient practice had the potential to prevent R16, R18, and R51 from receiving care that accommodated their individual care needs.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain a clean sanitary environment free of odor, replacing missing floor tiles, and ensure resident's equipment was free from rust on two of three halls.

Inspectors wroteBased on staff interview ,record review, and review of the facility policy titled, Care Planning Policy, the facility failed to develop a plan of care for two of 14 residents (R) (R16 and R40). Specifically, the facility failed to create a plan of care to monitor and prevent future occurrences of abuse for R16 and failed to develope a care plan for restorative services for R40.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Restorative Nursing, the facility failed to ensure three of 18 residents (R), (R18, R26, and R40) received services required to maintain or improve their functional abilities. Specifically, the facility failed to ensure R18 was provided with a Geri-chair that was properly fitted to ensure adequate body alignment, failed to provide equipment (footrest) for R26 to prevent potential for foot drop, and failed to provide Range of Motion (ROM) for left hand contracture for R40.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) for one of five residents (R) (R23) reviewed for Enhanced Barrier Precautions. This deficient practice had the potential to place R23 and other residents at risk for avoidable infections.